6.3                                                      Oral nutritional support
              Abbie Cawood
              Additional contributor: Rebecca Stratton
               Key points
               ■  The role of the dietitian is to provide evidence‐based advice on the most appropriate oral nutritional support for patients, and 
                  tailor dietary advice to their needs.
               ■  Oral nutritional support aims to improve the nutritional intake of macronutrients and micronutrients; approaches include 
                   fortified foods, snacks, nourishing drinks and oral nutritional supplements (ONS).
               ■  Dietary strategies improve intake, weight and body composition, and can have some benefits on functional outcomes, but 
                   clinical efficacy has not been fully assessed.
               ■  ONS has been shown to improve intake, weight, and body composition, with other clinical and economic benefits, e.g. 
                   improved function, reduced complications and readmissions to hospital.
               ■  All patients receiving oral nutritional support should be monitored regularly against the goals of the intervention.
              Oral nutritional support is a collective term used to         professionals should consider oral nutritional support to 
              describe the nutritional options available via the oral       improve nutritional intake in people who can swallow 
              route, to manage people who have been identified as           safely and are malnourished or at risk of malnutrition 
              malnourished or at risk of malnutrition (see Chapter 6.2,     (NICE, 2006a) (see Chapter 6.2, Malnutrition). This is 
              Malnutrition). Oral nutritional support should consider       an ‘A grade’ recommendation in the NICE CG32 Nutri­
              macronutrients (energy, carbohydrate protein, fat) and        tional Support in Adults (2006a), which is the highest 
              micronutrients (NICE, 2006a). Oral nutritional support        classification of recommendations based on the highest 
              options include any of the following methods to improve       level of evidence. NICE reviewed the evidence in 2014 
              nutritional intake, as defined by NICE (2006a):               and 2017 and found nothing to affect the recommenda­
              •	Fortified foods with protein, carbohydrate and/or fat       tions. Other national bodies also highlight the need for 
                plus vitamins and minerals.                                 nutritional management including:
              •	Snacks.                                                     •	Care Quality Commission (2015), as part of the Health 
              •	Altered meal patterns, practical help with eating.            and Social Care Act, which states that people must 
              •	Oral nutritional supplements (ONS).                           have their nutritional needs assessed, and that food 
              •	Provision of dietary advice – including all the preced­       must be provided to meet those needs; this includes            SECTION 6
                ing points, and tailoring counselling to the patient’s        prescribed nutritional supplements.
                clinical, nutritional, social and psychological needs.      •	Department of Health (2010) Essence of Care Frame­
              Who should receive oral nutritional support?                    work similarly highlights that nutritional support 
                                                                              should be considered for people who are at risk of 
              Oral nutritional support should be considered for               malnutrition or who are malnourished.
              patients with inadequate food and fluid intakes to meet       •	Statement 2 of NICE Quality Standard 24 states that 
              requirements, unless they cannot swallow safely, have           people who are malnourished or at risk of malnutrition 
              inadequate gastrointestinal function or if no benefit           should have a management care plan that aims to meet 
              is anticipated, e.g. end‐of‐life care (NICE, 2006a) (see        their nutritional requirements (NICE, 2012).
              Chapter 7.16, Palliative and end‐of‐life care). For other     •	British Dietetic Association (BDA, 2012) – Policy State­
              nutritional support options, see Chapter 6.4 Enteral nutri­     ment: The care of nutritionally vulnerable adults in 
              tion and Chapter 6.5, Parenteral nutrition. Healthcare          community and all health and care settings.
              Manual of Dietetic Practice, Sixth Edition. Edited by Joan Gandy. 
              © 2019 The British Dietetic Association. Published 2019 by John Wiley & Sons Ltd. 
              Companion website: www.manualofdieteticpractice.com
                344                                                                                       Section 6: Nutrition support
             Role of the dietitian in oral nutritional support                •	Fortifying milk by adding four tablespoons of skimmed 
             The role of the dietitian is to provide evidence‐based              milk powder to 1 pint of milk. This can then be used 
             advice on the most appropriate oral nutritional support             throughout the day in drinks, on cereals, or for custard, 
             option for the patient. The dietitian provides tailored die­        milk puddings, etc.
             tary advice according to the patient’s disease, symptoms         •	Adding grated cheese to soup, savoury dishes and 
             and treatment regimen, while considering the patient’s              mashed potato.
             social, physical, psychological, clinical and nutritional        •	Adding double cream to soup, mashed potato, sauces 
             needs. Advice may be given on dietary fortification (in             or desserts.
             addition to the encouragement to eat), food choice and           •	Adding butter or oil to vegetables, pasta and scram­
             preparation, and how to overcome anorexia or specific               bled egg, and during cooking.
             difficulties with eating, perhaps due to side effects or         •	Adding jam, syrup or honey to breakfast cereals, milk 
             symptoms associated with a disease or its treatment.                puddings or other desserts.
             Dietary strategies encompass food fortification, i.e. extra      •	Adding sugar to foods or drinks.
             snacks and nourishing drinks that can be used on their           •	Avoidance of low‐fat, low‐sugar and diet foods and 
             own or in combination with other nutritional support                drinks.
             strategies such as ONS and artificial nutrition. Individual        However, NICE (2006a) stated that care should be 
             patient needs should always be taken into consideration;         taken when using dietary fortification in isolation, as this 
             dietary strategies alone may be adequate for some                approach tends to supplement energy but not other nutri­
             patients, whereas, for others, ONS may be the most clini­        ents. Ideally, patients should be encouraged to fortify 
             cally effective option and should not be delayed.                their diets with foods that are energy and nutrient dense.
               The effectiveness of dietary advice will depend on               The use of food fortification may be an attractive option 
             many factors, including the method of counselling used,          for patients with anorexia, as the quantity and volume of 
             content and form of the advice given, and the patients           food consumed does not increase and familiar food ingre­
             themselves. The efficacy of dietary advice may be limited        dients are used. However, dietary fortification may alter 
             in the very sick, those with poor consciousness or limited       the sensory properties of foods, which may or may not 
             comprehension, and when there are possible time con­             be desirable for individual patients. Fortification using 
             straints in acute settings. In all settings, dietitians can      high‐fat foods (especially those with a high saturated 
             provide invaluable encouragement and advice (both                fat content, such as butter, cream and hard cheese) may 
             verbal and written) in the treatment of malnutrition and         not be desirable for some patients, e.g. those with high 
             in the nutritional management of many complex dis­               cholesterol levels. There may also be practical difficulties 
             ease states. However, dietetic services can sometimes be         on busy hospital wards or if patients are physically (e.g. 
             sparse, which means dietitians are unable to oversee the         disability or fatigue) or mentally unable or unwilling to 
             management of every individual who needs nutritional             modify their diets at home without help, thereby reducing 
             support. Therefore, dietitians have an important role as         compliance. For all patients, the costs of this approach 
             educators of medical, social care and nursing staff, par­        need to be considered, along with issues of purchasing, 
             ticularly in the primary and social care sectors, regarding      preparation and storage. Thought should also be given to 
             measures that can be taken to improve oral intake. There         dietary recommendations that other family members may 
             are several examples of evidence‐based pathways that             be following, and which may conflict with the strategies 
             have been developed nationally to improve the use of             for managing malnutrition, e.g. weight‐reducing advice 
             oral nutritional support, and specifically ONS. These can        for the management of obesity.
             be used by dietitians to support the development of local 
             guidelines for other healthcare professionals to follow, 
                                                                              Snacks
       SECTION 6e.g. managing adult malnutrition in the community 
             (www.malnutritionpathway.co.uk).                                 Additional food items in the form of snacks can be 
                                                                              used in the treatment of malnutrition with the aim of 
             Oral nutritional support strategies to improve                   increasing nutritional intake. As with food fortification, 
             nutritional intake                                               consideration should be given to improving energy, 
                                                                              protein and micronutrient intakes. Compliance with such 
             There are several oral nutritional support strategies avail­     a strategy may be good, as snacks are familiar and gen­
             able, as shown in Figure 6.3.1.                                  erally well liked. Examples include cake or malt loaf, 
                                                                              yoghurt, custard, toasted crumpets or teacakes with 
             Fortified food                                                   butter, and cheese and crackers. It may also be helpful 
                                                                              to recommend eating small amounts of food as snacks 
             The aim of food fortification should be to increase the          throughout the day. Snacks may not be effective in 
             nutrient density, and not the actual amount of food              patients with anorexia who may be unable to eat more 
             consumed. In practice, food fortification, primarily             food, or in patients with physical difficulties with eating 
             with the addition of energy‐rich foods, mostly results           (chewing, swallowing). For free‐living patients, there are 
             in increasing energy intakes. Food fortification practices       also cost considerations and issues of purchase, prepara­
             include the following:                                           tion and storage.
                   6.3  Oral nutritional support                                                                                                                              345
                         Low Risk                                    Screen for Malnutrition Risk,
                       ‘Routine care’                              e.g. with a tool such as MUST’
                        (‘MUST’ = 0)                                (See Chapter 6.2, Malnutrition)
                      This group may
                     have other dietetic                        Record details of malnutrition risk
                    needs which should
                     be considered e.g.                    Patient malnourished or at risk of malnutrition –
                       renal and liver
                     disease, diabetes,                          oral nutritional support indicated
                          obesity.              (consider and treat if appropriate, underlying cause of malnutrition) 
                                                                     Record risk category                          For additional nutrition
                                                             Set and agree goals of intervention                    support see Chapters
                                                                (e.g. prevent further weight loss)                       6.4 and 6.5
                                                       Consider needs for special diets e.g dysphagia
                                                            Consider any physical or social needs
                                                           e.g. dentures, ability to collect prescription
                                             Medium Risk                                            High Risk
                                                Monitor                                               Treat
                                              ('MUST' = 1)                                        ('MUST' = 2 - 6)
                     Where possible monitor food intake versus                  Maximise dietary intake and prescribe ready mvade
                     nutritional requirements to review need for oral           ONS
                     nutritional support                                        Where possible monitor intake versus nutritional
                     Consider maximising dietary intake                         requirements
                         - small frequent meals and snacks                      Consider patients clinical condition, nutritional and     Consider patients nutritional and
                                                                                social requirements, along with their preferences.        clinical requirements
                         - nourishing drinks including the use of               For ONS consider ACBS indications and use of              Consider ACBS indications
                          powdered supplements (to purchase, if                 starter packs in the community                            Asses preferences (consider starter pack) 
                          appropriate, or prescribe)                            Repeat screening (weekly in hospital, at least monthly
                                                                                in care homes and in the community)
                                                                                If no improvement consider referral to the dietetic
                                                                                team
                                                  Monitor and review progress of intervention against goals
                                            Continue to review patient until goals have been met, consider:
                                            Nutritional intake (full range of nutrients) and appetite
                                            Nutritional status including weight
                                            Compliance and acceptability of intervention
                                            Functional measures like strength, ability to perform daily activities
                                                     Stop oral nutritional support intervention if / when: 
                                            Goals of intervention have been met
                                            Patient is clinically stable and back to normal eating and drinking patterns 
                   Figure 6.3.1  Algorithm for oral nutrition support in the management of malnutrition
                   Nourishing drinks                                                                   Oral nutritional supplements (ONS)
                   As far as possible, patients should be encouraged to                                ONS, sometimes referred to as sip feeds, typically con­
                   consume drinks that are better sources of nourishment 
                                                                                                       tain a mix of macronutrients (protein, carbohydrate and                                   SECTION 6
                   than just tea, coffee or water. Liquids tend to be less                             fat) and micronutrients (vitamins, minerals and trace 
                   satiating than solid foods, so can be a good option                                 elements). As with tube feeds, ONS are foods for spe­
                   to increase the nutritional intake in patients with very                            cial medical purposes (FSMPs), and as such are regu­
                   poor appetites. Depending on individual patients and                                lated under the Foods for Specific Groups Regulation 
                   their clinical conditions, suitable suggestions include                             609/2013 and the Food Information for Consumers Reg­
                   the following:                                                                      ulation 1169/2011. These regulations define and catego­
                   •	Milky drinks, e.g. cocoa, drinking chocolate, malted                              rise the products, give compositional guidelines and set 
                      milk drinks, milkshakes, and coffee made with either                             out labelling requirements. These products are specially 
                      full‐fat milk, fortified milk, or calcium‐enriched  formulated, intended for the dietary management of 
                      alternatives.                                                                    patients who are unable to meet their nutritional needs 
                   •	Soup (especially condensed or ‘cream of’ varieties).                              through diet alone, and should be used under medical 
                   •	Fruit juices or smoothies (or drinks enriched with                                supervision. ONS can be prescribed in the community 
                      micronutrients).                                                                 (BMJ Group and the Royal Pharmaceutical Society of 
                   •	Powdered supplements that can be made up with water                               Great Britain, 2011) for the management of disease‐
                      or milk, e.g. Complan and Meritene; these can be pur­                            related malnutrition. Prescribing details can be found 
                      chased, although some are available on prescription.                             in the British National Formulary (BNF) section 9.4.2 
                 346                                                                                                 Section 6: Nutrition support
               (www.bnf.org). Other prescribable indications include                   (Hubbard et al., 2012). It should however be remem­
               short bowel syndrome, intractable malabsorption,  bered that the efficacy of ONS may be limited if compli­
               preoperative preparation of undernourished patients,                    ance is poor. Optimising compliance with ONS will pre­
               inflammatory bowel disease, total gastrectomy, bowel fis­               vent waste and maximise clinical benefits. Practical tips 
               tulae and dysphagia; dietitians can prescribe ONS. When                 to aid compliance could include the following:
               prescribing, the cost of ONS is often a consideration.                  •	Testing the patient’s preferences by offering a variety. 
               However, despite the enormous public expenditure on                        In the community, a prescribable starter pack of a 
               malnutrition (see Chapter  6.2, Malnutrition), that on                     range of types and flavours can be tried.
               treatments including ONS is low (∼1% of the overall                     •	Consider using varied flavours and a choice of differ­
               prescribing budget) (Stratton & Elia, 2010), and inter­                    ent types and consistencies. Note: Some patients are 
               ventions (mainly ONS) to combat malnutrition save                          also happy to use only one type and flavour.
               rather than cost money, with estimated net cost savings                 •	Encouraging ONS to be taken in small doses at inter­
               of £172.2–£229.2 million due to reduced healthcare                         vals throughout the day or as a medication as opposed 
               (Elia, 2015). Nevertheless, ONS, as with all forms of oral                 to a food.
               nutritional support, should be used appropriately.                      •	Using more energy‐ and nutrient‐dense ONS (Hubbard 
                 Most ONS are liquid feeds, although puddings and                         et al., 2012).
               powders are available (see Appendix A6). There are a                    •	Consider offering practical advice to patients, e.g. 
               range of types (high protein, fibre containing), styles                    serving ONS chilled or warmed, or using ONS within 
               (juice, milkshake, yoghurt, savoury, pre‐thickened),                       everyday recipes.
               energy densities (1–2.4 kcal/mL, or 4.18–10.0 kJ/mL)                    •	In some patient groups, e.g. the elderly or those 
               and flavours available to suit a wide range of patient                     with COPD, the combination of ONS with physical 
               needs. Most provide around 300 kcal (1.25 MJ), 12 g of                     activity programmes (resistance training) may facili­
               protein and a full range of vitamins and minerals per                      tate improvements in intake (Anker et al., 2006; Volkert 
               serving. ONS type, dose and duration are used according                    et al., 2006).
               to clinical judgement. However, most prescriptions 
               range from one to three supplements/day, with clinical 
               benefits typically seen with >300 kcal/day (1.25 MJ/day).               Other strategies
               Supplementation periods range from weeks (in elderly                    Other strategies that may help to increase dietary intake 
               patients who are acutely ill or post‐surgical) to months                include optimising dining room ambience, sensory 
               for chronically ill patients in the community. Many ONS                 enhancement of foods (flavour and odour enhancement), 
               are nutritionally complete when consumed in a certain                   use of music, and resistance training or exercise, partic­
               volume (2–7 servings/day, depending on the type of sup­                 ularly in the elderly living in long‐term care settings. In 
               plement); therefore, the supplement contains sufficient                 children, behavioural therapy may be useful.
               micronutrients to meet the daily requirements.
                 Liquid ONS tend not to suppress intake from normal 
               food, and, in some groups, may help to stimulate appe­                  Tailoring dietary advice for oral nutritional support 
               tite (NICE, 2006a; Stratton & Elia, 2007). ONS should not               (including practical considerations)
               replace the provision of good food or nutritional care                  Many factors can impair nutritional intake, with the main 
               (including help with feeding and meal provision) in                     factors being disease and its treatment (Stratton et al., 
               hospitals and care homes, or in a person’s own home.                    2003). Whenever possible, the underlying cause impairing            
               Patients likely to benefit from ONS across both hospital                intake should be identified and addressed. In addition to 
               and community settings include acutely ill hospitalised                 disease, other factors include social, functional, physical, 
               patients (especially the elderly, and hip fracture and gas­             mechanical and environmental issues; these differ 
       SECTION 6trointestinal surgical patients); malnourished patients 
               recently discharged from hospital; and those with chronic                depending on where the patient resides (own home, care 
               conditions such as cancer, chronic obstructive pulmonary                home, hospital, living alone, etc.). Considerations when 
               disease (COPD), neurological conditions, and renal and                  tailoring dietary advice for oral nutritional support may 
               liver disease (NICE, 2006a; Stratton & Elia, 2007). ONS                 include the following:
               are also used before and after surgery and perioperative­               •	Effect of the disease or its management (treatment, 
               ly, as part of the nationally recognised Enhanced Recovery                surgery), e.g. side effects such as nausea and vomit­
               After Surgery (ERAS) programme to improve outcomes                        ing, taste changes, dry or painful mouth, and the need 
               after surgery, reduce complications, and promote early                    for modified texture.
               discharge of patients (see Chapter 7.17.5, Surgery). Suit­              •	Ability to shop (physical, financial) or collect 
               ability of ONS for specific ethnic groups, people with                    prescriptions.
               allergies, vegans and those with other special require­                 •	Ability to prepare food or the need for assistance with 
               ments should always be checked.                                           eating.
                 Patients find ONS an acceptable form of nutritional                   •	Dentition, loss of appetite, fatigue, and early satiety, 
               support (NICE, 2006a), and compliance with ready‐made                     e.g. stomach resection, abdominal tumours or ascites 
               ONS has been shown to be good (78% of prescribed                          often result in people feeling full when consuming a 
               volume consumed), although this varies across settings                    small quantity of food.